Provider Demographics
NPI:1770575417
Name:PASADENA WOMEN'S MEDICAL GROUP, INC
Entity type:Organization
Organization Name:PASADENA WOMEN'S MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EBENEZER
Authorized Official - Middle Name:O
Authorized Official - Last Name:AJILORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-796-9114
Mailing Address - Street 1:50 ALESSANDRO PL
Mailing Address - Street 2:SUITE 310
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-3149
Mailing Address - Country:US
Mailing Address - Phone:626-796-9114
Mailing Address - Fax:626-796-8523
Practice Address - Street 1:50 ALESSANDRO PL
Practice Address - Street 2:SUITE 310
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3149
Practice Address - Country:US
Practice Address - Phone:626-796-9114
Practice Address - Fax:626-796-8523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA30816207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB50151Medicare UPIN